Sunday, June 5, 2011

The news of Jack Kevorkian's death brought out a large number of laudatory comments in The New York Times (laudatory about the man rather than his death, natch). "I hope that one day the world will look back on the service Dr. Kevorkian provided and will be shocked and saddened to learn that he was ostracized and incarcerated for the practice of providing dignity and some control to those in the late stages of terminal illness," SteveBnh of Virginia wrote in a representative sample of the praise heaped on the crusader for physician-assisted suicide.

Count me among the ostracizers. As the warm comments from seemingly well-informed readers demonstrates, Kevorkian was widely perceived to be a fierce advocate for patient's rights, a promoter of death with dignity, and the victim of a hypocritical and vindictive profession hellbent on maintain its Godlike power over patients. His trial, conviction, and imprisonment in 1999 for second-degree murder has the flavor of martyrdom, reinforcing the admiration of his followers and inviting comparisons to various legendary civil-rights activists.

In reality, Kevorkian was none of these things, but rather a creepy zealot obsessed with death who knew nothing about actual patient care. (I am not using the word "creepy" lightly; read on.) Although he was trained at a bonafide medical school and thus was a "doctor" in the general sense of the term, his training and subsequent practice was in pathology, where his work involved autopsies and analysis of human tissues on slides rather than actually taking care of living, breathing souls with joys and fears--making his public persona as "doctor" a bit misleading, as if he were the same as Marcus Welby, M.D. Kevorkian's nickname, "Doctor Death", didn't come from the notoriety he generated in the 1980s and '90s, but rather from perplexed and amused housestaff during his early days in a wry observation about his peculiar fixation on photographing patients' eyes at the precise moment of death. (Various blogs and websites supportive of Kevorkian state that this is because he wanted the profession to be able to distinguish the moment so that resuscitation could be performed, or something to that effect. It's utter nonsense: even in the 1950's, which some might consider the Dark Ages by medical standards, there were EKGs, a considerably more precise tool to determine death than staring into people's eyes, which seems positively medieval. Whatever his stated justifications, his "death photography" was pure fetish.) Long before he took up physician-assisted suicide as his cause, he bounced from hospital to hospital, disturbing various medical staffs with his distinctly unconventional preoccupations.

He was praised for his compassion despite the fact that he had not only not taken care of living patients except during his internship, but had never received any training of any kind in treating patients with depression (common enough among the terminally ill), palliative care, or any of the diseases that he claimed to treat. His choices reflect this very poor training: among the 130 or more cases in which he was the prescriber of death, several had no terminal illnesses nor were suffering, such as the case of Janet Adkins, who had been recently diagnosed with Alzheimer's disease but aside from mild memory loss was in otherwise reasonably good health.

I have heard Timothy Quill speak on two occasions and found him an eloquent man whose concerns are ultimately for the health and happiness of his patients. That said, I still believe that physician-assisted suicide is a terrible idea. Ironically, the two times I attended lectures by Dr. Quill mark dramatic shifts in opinion I have had on the subject: the first time happened before I started medical school and was strongly in favor of his ideas, while the second time was a few years ago, after I had undergone more than a decade of medical training, and my attitude had changed considerably.

It turns out that, not unlike the public misperceptions of Dr. Kevorkian, the picture of frequent, unremitting suffering of the terminally ill is for the most part a fiction. Curiously, over the past 20 or so years attitudes about physician-assisted suicide and euthanasia haven't changed a great deal among the general public or physicians in general (those numbers are different from one another, but stable over time). However, one group in which attitudes have changed significantly is among oncologists, who have had a steep drop in approval for those practices.

Why? It's hard to say with complete certainty, but it's likely because oncologists are more aware of, and tuned into, the multiple ways in which terminally ill patients can remain pain-free and finish their lives with meaning and dignity, to paraphrase the article in the link. A telling statistic: among oncologists, surgical oncologists, who deal with the long-term care of their patients far less often, were twice as likely to support physician-assisted suicide as their medical oncologist colleagues. In other words, the further away one gets from the actual practice of death and dying, the greater the fear of pain and suffering among laypeople and physicians alike, and the corresponding increase in support of physician-assisted suicide.

As for judging whether a life is worth living, that's much more straightforward. Physician's have no business judging the worth of any of their patients' lives. That is playing God.

It is not hard to kill onself in the US: over 30,000 people do it each year, and do it in a multiplicity of ways ranging from relatively peaceful to gruesome. And while there are technically laws on the books against suicide and no Supreme Court recognition of a "right to suicide," the practice is tacitly accepted. Suicides are allowed to be buried with everyone else, and the state does not seize their assets. So given the ease by which people can commit suicide, the debate around physicians being involved in the taking of lives has increasingly for me had an odd ring about it. Why must physicians be present to sanctify this process? It has the feel of approval-seeking, and docs shouldn't be in the business of approving or disapproving anything about a patient's lifestyle, except maybe smoking. Even then: maybe.

Doctors cannot take lives; it's not our job and should never be so. If we administer comfort medications that may hasten death to a suffering patient as a side effect, that is more than acceptable. If doctors withdraw tubes or machines that "artificially" keep patients alive, that's fine as well. But there's a big difference between maintaining a morphine drip and injecting a bolus of potassium chloride into a patient. The former is a drug with legitimate medical uses; the latter is never used under any conditions except to kill. Morphine is an everyday drug in hospices across the US; the potassium bolus was a "medication" unique to Dr. Kevorkian. May there never be another one like him again.
--br

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About Me

I'm a physician and an educator with a clinical focus in infectious disease. I teach the spectrum from 3rd year medical students through senior ID fellows, and try to keep everyone loose when doing so. Whether I succeed or not, you'll have to ask them.
I am interested in issues where medicine intersects with politics, as well as how medical research is portrayed by media. In some ways my views are very much at the fringe of the rest of the physician community, although in several other critical ways I’m your typical stethoscope-wielding, white-coat-wearing, reflex-hammer-tapping doc and consider myself steeped in the traditions of the brotherhood and sisterhood.